3C

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Little P, et al. "Antibiotic prescription strategies and adverse outcome for uncomplicated lower respiratory tract infections: prospective cough complication cohort (3C) study". BMJ. 2017. (357):j2148.
PubMed

Clinical Question

In patients with lower respiratory tract infections, how does the administration, timing or lack of antibiotics correlate to reconsultation of symptoms?

Bottom Line

When it comes to lower respiratory tract infections (LRTI) it may be more favorable to utilize a delayed antibiotic regimen. Patients who received delayed antibiotics experienced a resolution of symptoms and prevention of new symptoms when compared to immediate antibiotic treatment.

Major Points

This study was able to further evaluate the use of antibiotics, by elaborating on previous study results. Previous studies were not able to pinpoint any major adverse outcomes when it came to the use of antibiotics for the short term treatment of lower respiratory tract infections.

After conducting this study, it was found that major adverse events occur less than 1% of the time. A delayed antibiotic regimen should be utilized considering they provide a better resolution of symptoms and prevention of new onset of symptoms as well.


Guidelines

A structured protocol was used to document clinical presenting features of potential patients and management at the initial consultation. Physicians documented, age, smoking history, duration of symptoms, nature of symptoms, examination results, a rating of overall severity, and if antibiotics were prescribed. As far as guidelines used in the UK for treatment of LRTI there are various treatment algorithms. There is the British Thoracic Society, NICE (National Institute for Health Care and Excellence) algorithm, as well as SIGN (Scottish Intercollegiate Guidelines Network) guidelines.

Design

  • Prospective cohort study
  • N= 28,779
    • No antibiotics = 7,332 (25.4%)
    • Immediate antibiotics = 17,628 (61.3%)
    • Delayed antibiotics = 3,819 (13.3%)
  • Setting: 522 United Kingdom primary care facilities
  • Enrollment: October 2009 – April 2013
  • Mean follow-up: 30 days after initial consultation
  • Analysis:
  • Primary endpoint: Reconsultation in primary care or visit to an emergency department with progression of illness in 30 days after the index consultation, hospital admission or death

Population

Inclusion Criteria

  • Age ≥ 16 YOA
  • Lower respiratory tract infection with an acute infected cough as the main symptom (acute infected cough defined as a cough new or worsening for three weeks or less)

Exclusion Criteria

  • Other forms of acute cough (examples; heart failure, acid reflux, fibrosing alveolitis)
  • Immunocompromised
  • Inability to consent (example, mental illness)
  • Previous episodes of the same illness
  • Previous inclusion

Baseline Characteristics

  • Age > or = 60 years
    • No Antibiotics 28.8%
    • Immediate Antibiotics 42.3%
    • Delayed Antibiotics 33.4%
  • Female
    • No Antibiotics 60.7%
    • Immediate Antibiotics 58.6%
    • Delayed Antibiotics 59.8%
  • Illness duration <7 days
    • No Antibiotics 47.7
    • Immediate Antibiotics 50.2%
    • Delayed Antibiotics 42.1%
  • Received pneumovax <10 years
    • No Antibiotics 14.1%
    • Immediate Antibiotics 20.7%
    • Delayed Antibiotics 15.7%
  • Ever Smoked
    • No Antibiotics 49.4%
    • Immediate Antibiotics 56%
    • Delayed Antibiotics 49.2%

Outcomes

Primary outcome

Reconsultation in primary care or visit to an emergency department with progression of illness in 30 days after the initial consultation, hospital admission or death

No antibiotics No reconsultation = 5889 (26.4%) Reconsultation = 1443 (22.4%) Control group Immediate antibiotics No reconsultation = 13173 (59%) Reconsultation = 4455 (69.2%) Multivariable risk ratio controlling for clustering and significant covariates (95% CI) = 1 (0.92 to 1.08) P value = 0.94 Delayed antibiotics No reconsultation = 3281 (14.7%) Reconsultation = 538 (8.4%) Multivariable risk ratio controlling for clustering and significant covariates (95% CI) = 0.67 (0.60 to 0.76) P value = < 0.01

Secondary Outcomes

Hospital admissions or death after uncomplicated presentation and reconsultation with non-resolving or worsening symptoms

No antibiotics No hospital admission or death = 7306 (25.6%) Hospital admission or death = 26 (13.3%) Control Group Immediate antibiotics – Not significant No hospital admission or death = 17472 (61.3%) Hospital admission or death = 156 (79.6%) Multivariable risk ratio controlling for clustering and significant covariates (95% CI) = 1.65 (0.97 to 2.80) P value = 0.06 Delayed antibiotics – Not significant No hospital admission or death = 3805 (13.3%) Hospital admission or death = 14 (73%) Multivariable risk ratio controlling for clustering and significant covariates (95% CI) = 0.97 (0.49 to 1.92) P value = 0.92

Criticisms

  • There was no mechanism to ensure quality of the diagnostic skills used by the physicians.
  • Patients included in the trial were not blind to their antibiotic therapy or lack there of therapy.

Funding

  • Grant for independent research from the National Institute for Health Research (NIHR)

Further Reading